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Promoting wellbeing: A practical way to improve public mental health
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Contents
03 Introduction
03 1. Scale of the problem
• Millionsaffected
• Earlyonset
• Significantimpact
• Highcosts
06 2. Who is most at risk?
08 3. Why focus on wellbeing?
• Whatiswellbeing?
• Feelinggood
• Functioningeffectively
• Whyfocusonwellbeing?
• Preventspoormentalhealth
• Reducesburdenofdisease
• Improvesphysicalhealth
12 Conclusion
ThisdocumentwascreatedbyShift(formerlyknownasWeAreWhatWeDo)aspartoftheresearchphaseofaproduct/servicedevelopmentprocessaimedatimprovingwellbeingamongstyoungpeopleintheUK,commissionedbyTheNominetTrust.
ItwaswrittenbyKathleenCollett.
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Contact
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IntroductionMentalhealthisapublichealthissuewithcomplexcausesandseriousconsequences.Thispapergivesabriefoverviewofthescaleoftheimpactofpoormentalhealthonindividualsandsociety.Itgoesontoexploresomeofthefactorsthatputsomeindividualsatmoreriskofdevelopingmentalhealthproblemsthanothers,andexplainwhychildhoodandadolescenceareparticularlyimportanttimes
formentalhealthpromotion.Itlooksatwhatconstituteswellbeing,andtheevidenceforbelievingthatpromotingpositivewellbeingatthepopulationlevelcanreducetheincidenceofpoormentalhealth,andwellasincreasingthenumberofindividualswhoexperiencehighlevelsofwellbeing.Finally,itlooksatexistingproductsandservicesthataimtopromotewellbeing.
1. Scale of the problemMentalhealthproblemsrepresentthelargestsinglesourceofburdenofdiseaseintheUK.1Thismeansthatmentalhealthproblemsaccountformoreyearsofhealthylifelostthananyothersinglesourceofillness.2Forexample,in2004mentalhealthdisorders(includingself-inflictedinjury)accountedfor22.8%ofthetotalburdenofdisease,significantlymorethaneithercardiovasculardisease(16.2%)orcancer(15.9%).3
Millions affectedPartofthereasonthatmentalhealthdisordersaresuchamajorsourceofburdenofdiseaseintheUKisthatahighproportionofthepopulationisaffectedbypoormentalhealth.TheMentalHealthFoundationestimatesthateveryyeararound1in4peopleinBritainwillexperiencesomeformofmentalhealthproblem.4
Ofthosewhoexperiencementalhealthproblems,onlyaminorityhavepsychoticsymptomswhichinterferewithaperson’sperceptionofreality.TheRoyalCollegeofPsychiatristsreportsthatin2009,only0.4%ofthepopulationhadpsychosisandafurther5%hadsymptomsthatwereclinicallysignificantbutbelowthethresholdforthediagnosisofpsychosis(sub-thresholdpsychosis).5
Themajorityofthosewhoexperiencementalhealthproblemshave“neurotic” symptoms,whichareregarded
asextremeformsofnaturalemotionalexperiencessuchasdepression,anxietyorpanic.These“neurotic” symptomsarenowfrequentlycalled“common mental disorders”(CMDs).6
ThemostrecentAdultPsychiatricMorbiditySurvey,alargehouseholdsurveywhichprovidesdataonbothtreatedanduntreatedmentalhealthdisorders,suggestedthataround17.5%oftheUKpopulationsuffersfromcommonmentaldisordersatanyonetime,andthatasimilarproportionhave“symptoms which do not fulfil the full diagnostic criteria for common mental health disorder”.7GeneralisedAnxietyDisorder(GAD),depressivedisordersandmixedanxietyanddepressionarethemostprevalentcommonmentaldisorders,affecting5.8mpeopleinEnglandoutofatotalof6.1mpeoplesufferingfromcommonmentaldisorders.8
Thesefiguresarelikelytounderstatethenumberofpeopleexperiencingcommonmentaldisorders.TheNationalInstituteforHealthandClinicalExcellence(NICE)pointsoutthatdepressionandparticularlyanxietyoftengoundiagnosed.Under-recognitionisaparticularproblemforanxietydisorders,andNICEestimatesthatonlyasmallminorityofthosewhohaveanxietydisorderseverreceivetreatment.Thisispartlyduetounder-diagnosisbyGPs,butmayalsobedrivenbypatients’reluctancetoseekhelp,duetoconcernaboutstigma.9
1RoyalCollegeofPsychiatrists(2010)Nohealthwithoutpublicmentalhealth:Thecaseforaction,PositionStatementPS4/2010.London:RoyalCollegeofPsychiatrists.2BurdenofdiseaseismeasuredinDisabilityAdjustedLifeYears(DALYs).AccordingtotheWorldHealthOrganisation:”OneDALYcanbethoughtofasonelostyearof”healthy”life.ThesumoftheseDALYsacrossthepopulation,ortheburdenofdisease,canbethoughtofasameasurementofthegapbetweencurrenthealthstatusandanidealhealthsituationwheretheentirepopulationlivestoanadvancedage,freeofdiseaseanddisability”3RoyalCollegeofPsychiatrists(2010)Nohealthwithoutpublicmentalhealth:Thecaseforaction,PositionStatementPS4/2010.London:RoyalCollegeofPsychiatrists.4MentalHealthFoundation(2007)TheFundamentalFacts:Thelatestfactsandfiguresonmentalhealth.London:MentalHealthFoundation.5RoyalCollegeofPsychiatrists(2010)Nohealthwithoutpublicmentalhealth:Thecaseforaction,PositionStatementPS4/2010.London:RoyalCollegeofPsychiatrists.6MentalHealthFoundation(2007)TheFundamentalFacts:Thelatestfactsandfiguresonmentalhealth.London:MentalHealthFoundation.7McManus,S.,Meltzer,H,Brugha,Tetal(2009)AdultPsychiatricMorbidityinEngland2007.ResultsofaHosueholdSurvey,HealthandSocialInformationCentre,SocialCareStatistics.8Owncalculationsbasedonhttp://bit.ly/19oY8Ib9NICE(2011)Commonmentalhealthdisorders:Identificationandpathwaystocare,NICEclinicalguideline123.Manchester:NICE
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MentalIllnessinEngland(fromRoyalCollegeofPsychiatrists(2010)Nohealthwithoutpublicmentalhealth)
• 10%ofchildrenandyoungpeoplehaveaclinicallyrecognisedmentaldisorder:of5-to16-year-olds,6%haveconductdisorder,18%subthresholdconductdisorderand4%anemotionaldisorder
• 17.6%ofadultsinEnglandhaveatleastonecommonmentaldisorderandasimilarproportionhassymptomswhichdonotfulfilfulldiagnosticcriteriaforcommonmentaldisorder
• postnataldepressionaffects13%ofwomenfollowingchildbirth
• inthepastyear0.4%ofthepopulationhadpsychosisandafurther5%subthresholdpsychosis
• 5.4%ofmenand3.4%ofwomenhaveapersonalitydisorder;0.3%ofadultshaveantisocialpersonalitydisorder
• 24%ofadultshavehazardouspatternsofdrinking,6%havealcoholdependence,3%ilegaldrugsdependenceand21%tobaccodependence
• 25%ofolderpeoplehavedepressivesymptomswhichrequireintervention:11%haveminordepressionand2%majordepression;theriskofdepressionincreaseswithage-40%ofthoseover85areaffected
• 20-25%ofpeoplewithdementiahavemajordepressionwhereas20-30%haveminororsubthresholddepression
• dementiaaffects5%ofpeopleagedover65and20%ofthoseagedover80
• incarehomes,40%ofresidentshavedepressio,50–80%demetiaand30%anxiety
• athirdofpeoplewhocareforanolderpersonwithdementiahavedepression
Source:RoyalCollegeofPsychiatrists(2010)Nohealthwithoutpublicmentalhealth:Thecaseforaction,PositionStatementPS4/2010.London:RoyalCollegeofPsychiatrists.
Early OnsetAnotherfactorthatexplainswhymentalhealthissuchasignificantcontributortotheoverallburdenofdiseaseintheUKisthat,incomparisonwithdiseasessuchacardiovasculardiseaseandcancer,mentalhealthproblemsaffectpeoplewhentheyarerelativelyyoung.1in10youngpeopleaged5–16inGreatBritainhadaclinicallydiagnosedmentaldisorderaccordingtoamajornationalstudyofthementalhealthofchildrenandyoungpeoplein2004.10Further,studiesbyKim-CohenetalandKessleretalfindthathalfofallcasesofmentalhealthdisorderstartbyage14yearsandthreequartersbyage24years.11,12
Thementalhealthproblemsyoungpeopleexperienceoftenpersistintoadulthoodinarelatedform.Forexample,youngpeoplewhoexperiencedepressioninmid-adolescence(14-16yearsold)aremorelikelytoexperiencemajordepressionandanxietydisordersasadults,evenonceconfoundingsocial,familialandindividualfactorsaretakenintoaccount.13Similarly,youngpeoplewithjuvenileanxietydisordersareat
ahigherriskofanxietydisordersandmajordepressioninlaterlife.Again,thislinkpersistsevenonceothercontributingsocial,familialandindividualcharacteristicsaretakenintoaccount.14
Mentalhealthproblemsinearlylifealsoprecedethedevelopmentofdifferenttypesofmentalhealthproblemsinlaterlife.Forexample,conductdisorderandoppositionaldefiantdisorders,characterisedby“a pattern of repeated and persistent misbehaviour”,precedeawidevarietyofadultmentalhealthdisorders.AccordingtoRichardsonandJoughin“approximately 40-50% of children with conduct disorder go on to develop antisocial personality disorder as adults”butconductdisorderisalsolinkedtoothernegativeoutcomessuchassubstancemisuse,mania,schizophrenia,obsessive-compulsivedisorder,majordepressivedisorderandpanicdisorderinlaterlife.15
Theearlyonsetofmentalhealthproblemsmeansthatthoseaffectedoftenexperiencementalhealthissuesthroughoutlargeportionsoftheirlives,includingcrucialyearsforsocialandcareerdevelopment.
10Green,H.,McGinnity,Á.,Meltzer,H.,Ford,T&Goodman,R.(2004)MentalhealthofchildrenandyoungpeopleinGreatBritain,2004:AsurveycarriedoutbytheOfficeforNationalStatisticsonbehalfoftheDepartmentofHealthandtheScottishExecutive.London:ONS.11Kim-CohenJ,CaspiA,MoffittTE,HarringtonH,MilneBJ,PoultonR.(2003)Priorjuvenilediagnosesinadultswithmentaldisorder:developmentalfollow-backofaprospective-longitudinalcohort.ArchivesofGeneralPsychiatry60(7):709-17.12Kessler,R.,Berglund,P.,Demler,O.,Jin,R.,Merikangas,K.&Walters,E.(2005)Lifetimeprevalenceandage-of-onsetdistributionsofDSM-IVdisordersintheNationalComorbiditySurveyReplicationArchivesofGeneralPsychiatry62(6):593-602.13FergussonDM,WoodwardLJ.(2002)Mentalhealth,educational,andsocialroleoutcomesofadolescentswithdepression.ArchivesofGeneralPsychiatry59(3):225-31.14FergussonDM,WoodwardLJ.(2002)Mentalhealth,educational,andsocialroleoutcomesofadolescentswithdepression.ArchivesofGeneralPsychiatry59(3):225-31.15Richardson,J&Joughin,C.(2002)ParentTrainingProgrammesfortheManagementofYoungChildrenwithConductDisorders:FindingsfromResearch.London:RoyalCollegeofPsychiatrists.
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Significant impactThefinalreasonwhymentalhealthcontributessomuchtotheoverallburdenofdiseaseisthatithassuchasignificantimpactonthelivesofthosewhoitaffects.Theextentoftheimpactofmentalhealthproblemsisoftennotfullyrecognisedasconnectionsbetweenmentalhealthandotheraspectsofhealthandwellbeingarenotalwaysapparentandaremosteasilyseenatthepopulationlevelratherthanattheindividuallevel.
Theimpactofpoormentalhealthbeginsearly.Childrenandyoungpeoplewhoexperiencementalhealthproblemsaremorelikelytohavepooreducationalachievement,withnegativeconsequencesforcareerdevelopmentandearnings.Theyarealsoatagreaterriskofsuicideandsubstancemisuse,anti-socialbehaviour,offendingandearlypregnancy.Poormentalhealthinchildhoodandadolescenceisalsoassociatedwithpoorhealthandsocialoutcomesinadulthood.16
Overthelifecourse,peoplewhoexperiencementalillnessexperiencemorephysicalillness,andhavealowerlifeexpectancy.17Depressioninparticularisstronglycorrelatedwithcardiovasculardiseaseandcancer:mortalityfromcardiovasculardiseaseis67%higherinthosewhoaredepressed,andmortalityfromcanceris50%higher.18AlargecohortstudyinNorwayshowedthatdepressionsignificantlyincreasedmortalityfrombothcardiovasculardiseaseandalsoallothercauses,evenaftertakingintoaccounthealth-relatedbehaviours(smoking,alcoholuse,andphysicalactivity),physicalsymptomsandimpairments,educationandsocioeconomicstatus,andphysicalmeasurementssuchasbodymassindex,bloodpressureandcholesterol.19
Individualswhoexperiencementalhealthproblemsaremorelikelytoself-harm,andareatahigherriskofsuicide.Suicideisthethirdlargestcontributortoprematuremortality(afterheartdiseaseandcancer)inBritain.20TheRoyalCollegeofPsychiatristsreportsthat“in some studies, the rate of a diagnosed mental illness of those who have killed themselves has been found to be more than 80%”,andtherateofsuicideamongstthosewithseverementalillnessis12timeshigherthaninthegeneralpopulation.21Self-harmbehaviourisalsomorecommonamongstthosewithamentaldisorder.22Self-harmandsuicidearestatisticallylinked:recentstudiessuggestthatthosewhoself-harmareatan
approximately30-foldgreaterriskofsuicide,comparedwiththegeneralpopulation.23
Mentalhealthproblemsareassociatedwithlowerlevelsofself-carebehaviour,andhigherlevelsofriskyhealthbehaviours.AlmosthalfofalltobaccointheUKisconsumedbythosewhohaveamentalhealthdiagnosis.24Smokingsignificantlyincreasestheriskofmanyseriousdiseases,andreduceslifeexpectancy.Mentalillness,particularlymajordepression,increasestheriskofobesity.25Depressionmayalsoaffectthewaythatindividualsseekhelpforhealthproblems,withtheconsequencethatphysicalillnessesarediagnosedatamoreadvancedstagethantheymightotherwisehavebeen,anditmayreduceadherencetotreatmentplans,negativelyaffectingtheirhealthoutcomes.26
Poormentalhealthisalsoassociatedwithalcoholmisuse.Ratesofalcoholmisusearemuchhigheramongstthosewithpoormentalhealth.Youngpeoplewithanemotionalorconductdisorderare2-4timesmorelikelytodrinkregularly(morethantwiceaweek).27Alcoholconsumptionmayalsocontributeorworsenmentalhealthproblems:highlevelsofalcoholconsumptionare“associated with higher levels of depressive and affective problems, schizophrenia and personality disorders.”28
Theeffectsofmentalillnessspilloutfarbeyondtheindividualaffected.Peoplewithmentaldisordersaremorelikelytobevictimsofcrimeandviolencethanperpetrators.29Atthesametime,mentalillnessisanimportantfactorintheproblemofcrimeatthepopulationlevel.TheSainsburysCentreforMentalHealthestimatesthat“around 80% of all criminal activity is attributable to people who had conduct problems in childhood and adolescence, including about 30% specifically associated with conduct disorder.”30Theriskofviolentbehaviourissignificantlyincreasedonlyforthosewhomisusealcoholanddrugs.31
Mentalhealthalsohasalargeimpactonworkandproductivity.Whileemploymentcanprovideagrouptobelongto,anincomeandasenseofpurpose,workcanalsobestressfulandinsecure.Around11.4millionworkingdaysarelostannuallyinBritainduetowork-relatedstress,anxietyordepression.32
Forthosewithmentalhealthproblems,itismoredifficulttofindandremaininproductiveemployment,andmentalillnessisconsequentlyassociatedwith
16RoyalCollegeofPsychiatrists(2010)Nohealthwithoutpublicmentalhealth:Thecaseforaction,PositionStatementPS4/2010.London:RoyalCollegeofPsychiatrists.17RoyalCollegeofPsychiatrists(2010)Nohealthwithoutpublicmentalhealth:Thecaseforaction,PositionStatementPS4/2010.London:RoyalCollegeofPsychiatrists.18RoyalCollegeofPsychiatrists(2010)Nohealthwithoutpublicmentalhealth:Thecaseforaction,PositionStatementPS4/2010.London:RoyalCollegeofPsychiatrists.19Mykletun,A.,Bjerkeset,O.,Dewey,M.,Prince,M.,Overland,S.&Stewart,R.(2007)Anxiety,Depression,andCause-SpecificMortality:TheHUNTStudyPsychosomaticMedicine69:323–331.20RoyalCollegeofPsychiatrists(201)Self-harm,suicideandrisk:helpingpeoplewhoself-harm.CollegeReportCR158.London:RoyalCollegeofPsychiatrists.21RoyalCollegeofPsychiatrists(201)Self-harm,suicideandrisk:helpingpeoplewhoself-harm.CollegeReportCR158.London:RoyalCollegeofPsychiatrists.22RoyalCollegeofPsychiatrists(2010)Nohealthwithoutpublicmentalhealth:Thecaseforaction,PositionStatementPS4/2010.London:RoyalCollegeofPsychiatrists.23RoyalCollegeofPsychiatrists(201)Self-harm,suicideandrisk:helpingpeoplewhoself-harm.CollegeReportCR158.London:RoyalCollegeofPsychiatrists.24RoyalCollegeofPsychiatrists(2010)Nohealthwithoutpublicmentalhealth:Thecaseforaction,PositionStatementPS4/2010.London:RoyalCollegeofPsychiatrists.25RoyalCollegeofPsychiatrists(2010)Nohealthwithoutpublicmentalhealth:Thecaseforaction,PositionStatementPS4/2010.London:RoyalCollegeofPsychiatrists.26Mykletun,A.,Bjerkeset,O.,Dewey,M.,Prince,M.,Overland,S.&Stewart,R.(2007)Anxiety,Depression,andCause-SpecificMortality:TheHUNTStudyPsychosomaticMedicine69:323–331.27RoyalCollegeofPsychiatrists(2010)Nohealthwithoutpublicmentalhealth:Thecaseforaction,PositionStatementPS4/2010.London:RoyalCollegeofPsychiatrists.28RoyalCollegeofPsychiatrists(2010)Nohealthwithoutpublicmentalhealth:Thecaseforaction,PositionStatementPS4/2010.London:RoyalCollegeofPsychiatrists.29RoyalCollegeofPsychiatrists(2010)Nohealthwithoutpublicmentalhealth:Thecaseforaction,PositionStatementPS4/2010.London:RoyalCollegeofPsychiatrists30SainsburyCentreforMentalHealth(2009)Thechanceofalifetime:Preventingearlyconductproblemsandreducingcrime.London:SainsburyCentreforMentalHealth.31RoyalCollegeofPsychiatrists(2010)Nohealthwithoutpublicmentalhealth:Thecaseforaction,PositionStatementPS4/2010.London:RoyalCollegeofPsychiatrists.32RoyalCollegeofPsychiatrists(2010)Nohealthwithoutpublicmentalhealth:Thecaseforaction,PositionStatementPS4/2010.London:RoyalCollegeofPsychiatrists.
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anincreasedlikelihoodofunemployment.Only20%ofthoseusingspecialistmentalhealthservicesareinpaidworkorfull-timeeducation.33Thesocialexclusionandfinancialchallengesexperiencedbymanyofthosewhoareunemployedcaninturncontributetopoormentalhealth,leadingtoaviciouscycle.
Despitenationalcampaignstoraiseawarenessoftheimportanceofmentalhealthandreducethestigmaattachedtomentalhealthdiagnoses,discriminationstillcompoundstheimpactofmentalhealthproblemsformanyindividuals.TheRoyalSocietyofPsychiatristsalsopointsoutthatpeoplewithmentalhealthproblemsexperienceexclusionalongavarietyofdimensions(economic,social,politicalexclusionandalsoserviceexclusion),compoundinginequality,whichisitselfariskfactorforpoormentalhealth.
High costsBecausementalhealthproblemsstartsoearly,andbecausetheyhavesuchsignificantandwide-rangingconsequencesfortheindividualsdirectlyaffectedandthoseconnectedwiththem,theeconomicburdenofpoormentalhealthisverylargeindeed.TheRoyalCollegeofPsychiatristsestimatesthatthewidercostsofmentalillnessinEnglandare£105.2
bnayear.In2007,thedirectcostsofmentalhealthtoNHSwere£10.4bn,andtheCentreforMentalHealthestimatedthatthecombinedcostsofhealthandsocialcare,includingNHSandlocalauthorityservicesforpeoplewithmentalhealthproblems,wereapproximately£21.3bnin2009/2010.34
Thereisaparticularlystrongeconomiccaseofearlyintervention.Theeconomicevaluationofcoststosocietyofmentalillnessinchildrenandadolescentshasproducedestimatesrangingfrom£11,030to£59,130perchildperyear.35TheNationalCAMHSSupportServicepointstostudiesthatshowthatpublicservicescouldsave£100meveryyearbydeliveringearlyinterventionservicestojust1in10oftheyoungpeoplereceivingprisonsentences,andthat£50mperyearcouldbesavedbyprovidingearlyinterventionservicesforpatientswithpsychosis.36
Itisclearthatmentalhealthisamajorpublichealthissue,anditsdevelopmentisheavilyinfluencedbyearlyexperiencesandshapedbyriskfactorsinearlylife.Whatcanbedonetopreventthedevelopmentofpoormentalhealth?Understandingwhatthetypicalriskfactorsareforthedevelopmentofpoormentalhealthisvital,asisidentifyingprotectivefactorsthatcouldhelppreventthedevelopmentofpoormentalhealth.
2. Who is most at risk?Mentalhealthisamajorpublichealthproblem,whichiswidelyprevalent,startsearlyandhasamajorimpactonqualityoflife.Manyoftheconsequencesofpoormentalhealthinfactreinforcepoormentalhealthinaviciouscycle.Butwhatarethefactorsthatpredisposepeopletomentalhealthdisorders?
Certaingroupsofindividualsareathigherriskofdevelopingmentalhealthproblems.Overall,intheUKwomenaremorelikelytohaveacommonmentalhealthdisorderthanmen.A2007UKhouseholdsurveyfoundthatnearly1in5womenhadacommonmentaldisordercomparedwithonly1in8men.37
Thesamestudyfoundthatratesofcommonmentaldisordervariedbyage.Theoldestgroupinthesurvey(thoseaged75andover)hadthelowestincidenceofcommonmentaldisorderwithonly6.3%ofmenand12.2%ofwomenexperiencingdisorders.Womenbetween45and54yearsoldhadthehighestrate:overaquarter(25.2%)ofthisgroupmetthecriteriaforatleastoneCMD.Formen,therateofCMDspeakedbetween25and54yearsold(14.6%of25–34yearolds,15.0%of35–44yearolds,14.5%of45–54yearolds).38
Thoselivinginhouseholdswithlowerlevelsofincomearemorelikelytoexperiencecommonmentaldisordersthanthoseinhouseholdswithhigherlevelsofincome.MacManusetal(2009)foundthat23.5%ofmeninthelowesthouseholdincomegrouphadaCMD,comparedtoonly8.8%ofthoseinthehighestincomehouseholds,afteradjustingforage.39
ThesestatisticssummarisetheincidenceofCMDsfordifferentgroupsoftheadultpopulation.Alongsideage,genderandincome,therearealsoalargenumberofotherriskfactorswhichcontributetothedevelopmentofpoormentalhealth.Because75%ofmentalhealthdisordersstartinchildhoodorearlyadulthood,riskfactorsforthedevelopmentofpoormentalhealthearlyinlifeareparticularlyrelevanttounderstandingthefactorsthatputindividualsatgreaterrisk.
Riskfactorsinthedevelopmentofmentaldisordersamongyoungpeoplecanbeidentifiedattheindividuallevel,familylevel,schoollevelandatthelevelofcommunityandculture.Someriskfactorsalsorelatetospecificlifeevents,suchastraumaorloss.40,41Thefactorsexploredbelowareoverallriskfactorsforthedevelopmentofmentalillnessingeneral–riskfactorsforparticularillnesseswillbedifferent.
33RoyalCollegeofPsychiatrists(2010)Nohealthwithoutpublicmentalhealth:Thecaseforaction,PositionStatementPS4/2010.London:RoyalCollegeofPsychiatrists.34CentreforMentalHealth(2010)Theeconomicandsocialcostsofmentalhealthproblemsin2009/10London:CentreforMentalHealth.35RoyalCollegeofPsychiatrists(2010)Nohealthwithoutpublicmentalhealth:Thecaseforaction,PositionStatementPS4/2010.London:RoyalCollegeofPsychiatrists.36NationalCAMHSSupportService(2011)Bettermentalhealthoutcomesforchildrenandyoungpeople:aresourcedirectoryforcommissioners.London:NationalCAMHSSupportService(NCSS)37McManus,S.,Meltzer,HmBrugha,Tetal(2009)AdultPsychiatricMorbidityinEngland2007.ResultsofaHosueholdSurvey,HealthandSocialInformationCentre,SocialCareStatistics.38McManus,S.,Meltzer,HmBrugha,Tetal(2009)AdultPsychiatricMorbidityinEngland2007.ResultsofaHosueholdSurvey,HealthandSocialInformationCentre,SocialCareStatistics.39McManus,S.,Meltzer,HmBrugha,Tetal(2009)AdultPsychiatricMorbidityinEngland2007.ResultsofaHosueholdSurvey,HealthandSocialInformationCentre,SocialCareStatistics.40Kutz,Z.(2009)TheEvidenceBasetoGuideDevelopmentofTier4CAMHS.London:DepartmentofHealth41RoyalCollegeofPsychiatrists(2010)Nohealthwithoutpublicmentalhealth:Thecaseforaction,PositionStatementPS4/2010.London:RoyalCollegeofPsychiatrists.
Community and culture
socio-economicdisadvantage
socialorculturaldiscrimination
isolation neighbourhoodviolenceorcrime
deviantpeergroup highpopulationdensityandpoor
housingconditions
lackofsupportservices,includingtransport,shoppingandrecreational
facilities
Life events and situations
physical,sexualoremotionalabuse
changingschoolsfrequently
unemployment
divorceandfamilybreak-up
deathoffamilymember
homelessness
physicalillnessordisability
incarceration
povertyoreconomicinsecurity
jobinsecurity
unsatisfactoryworkplace
relationships
workplaceaccidentorinjury
caringforsomeonewithanillnessor
disability
livinginanursinghome
warornaturaldisasters
School
bullying peerrejection poorattachmenttoschool
inadequatebehaviour
management deviantpeergroup
failureatschool
Family
havingateenagemotherorasingleparent
absenceoffatherinchildhood
largefamily
antisocialrolemodelsinchildhood
familyviolenceordisharmony
maritaldiscordinparents
poorsupervisionormonitoring
neglectinchildhood
lowparentalinvolvementinchild’sactivities
long-termparental
unemployment
criminalityinparent
parentalsubstancemisuse
parentalmentaldisorder
harshorinconsistent
disciplinestyle
socialisolation
experiencesofrejection
lackofwarmthandaffection
Individual
prenatalbraindamage
prematurebirth
birthinjury
lowbirthweight,birth
complications
physicalorintellectualdisability
poorhealthininfancy
insecureattachmentininfantorchild
lowintelligence
difficulttemperament
chronicillness
poorsocialskills
lowself-esteem
alienation
impulsivity
Figure 1: Risk factors for developing mental illness
Basedon:ChildrenandMentalHealthKnowledgeExchange(2007)Bestpracticesguidelinesformentalhealthpromotionprograms
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Thefollowinggroupsareathigherriskthantheirpeersformentalhealthproblems:
Becauseexperiencesinchildhoodand
adolescenceplaysuchakeyroleinthedevelopmentofanindividual’smentalhealth,thisisakeypointforintervention.
Table 1: Impact of risk factors on prevalence of any mental disorder
Risk Factor Expected prevalence of mental disorder
Lookedafterchildren 45%
ChildrenwithSpecialEducationalNeedsrequiringstatutoryassessment
44%
Childwithlearningdisability 22%
Householdswithnoworkingparent 20%
Childabsentfromschoolmorethan11daysinayear 19%
Parentalmentalillness 18%
5ormorechildreninhousehold 18%
Loneparentfamilies 16%
Childrenlivinginlessprosperous/mixedareas 16%
Parentswithnoeducationalqualifications 15%
3. Why focus on wellbeing?Untilrelativelyrecently,thedefactoapproachtoaddressingmentalhealthhasbeenacombinationoftreatmentforthosewhoareexperiencingmentalhealthproblemsandinitiativesaddressingriskfactorsformentalhealthtargetedatgroupsathighriskofdevelopingmentalhealthproblems.Recently,however,therehasbeenrecognitionthatthisapproachhasnotbeensufficienttoreduce“the prevalence, burden, or early onset of mental disorder”.42
Toaddressthepublichealthissuethatmentalhealthposes,majorpublichealthbodiesandpsychologicalandpsychiatricassociationsincreasinglybelievethatthefocusshouldbeondevelopingandprotectingpositivementalhealthormentalwellbeing,asawayofpreventingmentalhealthproblems.Mentalhealthpromotionisnowseenasanessentialpartofpublicmentalhealth,inadditiontoinitiativesthatreduceriskfactorsformentalhealthproblems,andtheprovisionoftreatment.
What is wellbeing?Goodmentalhealthormentalwellbeingismorethantheabsenceofmentalillness.TheWorldHealthOrganisationdefinespositivementalhealthas:“a state of wellbeing in which every individual realises his or her own potential, can cope with the normal stresses of life, can work productively and fruitfully, and is able to make a contribution to her or his community… Health is a state of complete physical, mental and social wellbeing and not merely the absence of disease or infirmity.”43Wellbeingisnowwidelyunderstoodashavingtwokeydimensions.
Feeling goodOnedimensionofwellbeingrelatestoindividual’ssubjectiveexperience.FeliciaHuppertattheWell-beingInstituteatCambridgesimplydescribesthisas“feeling good”.Othershavecalleditsubjective
wellbeingorhedonicwellbeing.AccordingtoDiener,Suh,LucasandSmith,subjectivewell-beinghasthreeinterrelatedcomponents:“life satisfaction (an overall cognitive sense of satisfaction with one’s life), pleasant affect (enjoyable moods and emotions), and unpleasant affect.”45
Functioning effectivelyAnotheraspectofwellbeingreferstohoweffectivelyanindividualisabletofunction.Thisisoftencalledpsychologicalwellbeingoreudaimonicwellbeing.AninfluentialmodeldevelopedbyRyff(2006)suggeststhatpsychologicalwellbeingisconstitutedbyself-acceptance,positiverelationswithothers,autonomy,environmentalmastery,purposeinlifeandpersonalgrowth.Huppertdescribestheseaspectsas”developing one’s potential, having some control
42Keyes,C.,Dhingra,S.,Simoes,E.(2010)ChangeinLevelofPositiveMentalHealthasaPredictorofFutureRiskofMentalIllness.AmericanJournalofPublicHealth,100(12)43WorldHealthOrganisation(2013)Mentalhealth:astateofwell-being.Downloadedfrom<http://www.who.int/features/factfiles/mental_health/en/>44Huppert,F.(2009)PsychologicalWell-being:EvidenceRegardingitsCausesandConsequences.AppliedPsychology:HealthandWellbeing1(2):137-164.45Diener,E.,Suh,E.,Lucas,R.&Smith,H.(1999)SubjectiveWell-being:Threedecadesofprogress.PsychologicalBulletin,Vol125(2),Mar1999,276-302.46Huppert,F.(2009)PsychologicalWell-being:EvidenceRegardingitsCausesandConsequences.AppliedPsychology:HealthandWellbeing1(2):137-164.
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over one’s life, having a sense of purpose, including working towards valued goals, and experiencing positive relationships.”46
Huppertpointsoutthat“sustainable well-being does not require individuals to feel good all the time: the experience of painful emotions is a normal part of life, and being able to manage these negative or painful emotions is essential for long-term well-being. Psychological well-being is, however, compromised when negative emotions are extreme or very long-lasting and interfere with a person’s ability to function in his or her daily life.”47
Wellbeingisdistinctfromtheabsenceofmentalhealthproblems.Thereisnowasignificantamountofevidencethatwhilesomeofthefactorsthatcontributetomentalillnessandmentalwellbeingarethesame,othersarenot.48Keyes,forexample,suggeststhatthefindingsfrommanystudieswhichexaminetherelationshipbetweenwellbeingandmentalillnesssupporttheideathattherearetwocontinuumsrelevanttomentalhealth:“one indicating the presence or absence of mental health, the other indicating the presence or absence of mental illness symptoms.”49Keyesarguesthatthetwoshouldbeunderstoodasseparateaspectsofmentalhealth.
Mentalwellbeingisoftenrepresentedonacontinuumfromflourishingtolanguishing.Theconceptofflourishingisoftenusedtodescribethewhatmentalhealthdevelopmentshouldaimat.FredricksonandLosadadescribeflourishingasliving“within an optimal range of human functioning, one that connotes goodness, generativity, growth, and resilience.”50Theterm“languishing”isusedtodescribetheotherendofthecontinuum,whereindividualsexperienceunhappinessandstagnationbutnotnecessarilymentalillness.
Althoughmentalwellbeingtendstoimproveasmentalillnesssymptomsdecrease,thisisnotalwaysthecase.51Bolier,HavermanandBohlmeijerexplainthat“people can be free of mental illness and at the same time be unhappy and exhibit a high level of dysfunction in daily life … . Likewise, people with mental disorders, can be happy by coping well with their illness and enjoy a satisfactory quality of life”.52Thisperspectivehasbeenadoptedatthepolicylevelinseveralcountries.Forexample,theScottishGovernmentsuggestthat“someone can experience signs and symptoms of mental illness and still have good or flourishing mental well being … just as people with a physical illness or condition can live positively, flourish and have a good sense of wellbeing”.53
Why focus on wellbeing?
Prevents poor mental health Variousstudiessuggestthatgoodmentalwellbeingcanactasabufferforpoormentalhealth.Psychologistswhofocusontheprotectiveeffectofwellbeingonmentalhealtharguethatknocks,stressors,traumasandlossesareinevitableinlifeandcanhaveahugeimpactonaperson’sstateofmentalwellbeing,particularlyinrelationtoCMDssuchasanxietyanddepression.Acoreaimofmentalhealthpromotionistohelppeopletobuildthecognitiveandemotionalresourcesthattheyneedinorderto“cope”notonlyintimesofcalmbutalsointimesoftrouble,inorderthattheriskoftriggeringaCMDisreduced.
MartinSeligman,anearlyproponentoftheideathatpsychologyshouldfocusonunderstandingandpromotingfullhumanflourishingaswellasaddressingdysfunction,arguedthat“nurturing human strengths such as optimism, courage, future mindedness, honesty and perseverance serve as more efficacious buffers against mental illness as compared to medication or therapy”.54
Theviewthatgoodmentalhealthprotectsagainstmentalillnesshasfoundempiricalsupportinseveralstudies.
Forexample,thereisevidencethatwellbeingprotects
againstthenegativeeffectsofstressonmentalhealth.Grant,GuilleandSen(2013)assessedthewellbeinglevelsof1621medicalinternsdirectlybeforetheystartedtheirinternships,anexperiencerecognisedtobestressfulandatimeduringwhichdepressivesymptomsareknowntoincreasesignificantly.Thoseinternswhohadhigherlevelsofwellbeingatthestartoftheirinternshipsshowedasmallerincreaseindepressivesymptomsoverthe3monthsofthestudy.55
Thereisalsoevidencethatmaintaininggoodlevelsofwellbeingisassociatedwithalowerlikelihoodofdevelopingamentalillness.Keyesetal,inalarge10yearfollow-upstudy,foundthatindividualsthatwerelanguishingatboththebeginningandtheendofthe10yearperiodweremorethan6timesaslikelytohaveamentalillnessattheendoftheperiodcomparedtothosewhohadstayedflourishingatbothpoints.Theyalsofoundthatgainsinmentalhealthdecreasedthelikelihoodofexperiencingamentalillnesswhilelossesinmentalhealthincreasedit.Inall,theirstudyprovidessupportforthehypothesisthatpromotingandprotectinggoodmentalhealthcanprotectagainstthedevelopmentofmentalillness.56
Reduces the burden of diseaseSmallimprovementsinwellbeingcouldsignificantlyreducetheincidenceofmentalhealthdisordersinthepopulation.
47Huppert,F.(2009)PsychologicalWell-being:EvidenceRegardingitsCausesandConsequences.AppliedPsychology:HealthandWellbeing1(2):137-164.48Huppert,F.(2009)PsychologicalWell-being:EvidenceRegardingitsCausesandConsequences.AppliedPsychology:HealthandWellbeing1(2):137-164.49Keyes,C.,Dhingra,S.,Simoes,E.(2010)ChangeinLevelofPositiveMentalHealthasaPredictorofFutureRiskofMentalIllness.AmericanJournalofPublicHealth,100(12)50Fredrickson,B.&Losada,M.(2005)PositiveAffectandtheComplexDynamicsofHumanFlourishing.TheAmericanPsychologist60(7):678-686.51Keyes,C.(2002)TheMentalHealthContinuum:FromLanguishingtoFlourishinginLife.JournalofHealthandSocialBehavior,43(2):207-222.52Bolier,L.,Haverman,M.,Westerhof,G.,Riper,H.,Smit,F.,Bohlmeijer,E.(2013).Positivepsychologyinterventions:ameta-analysisofrandomizedcontrolledstudies.BMCPublicHealth,13:119.53TheScottishGovernment(2007)TowardsaMentallyFlourishingScotland:TheFutureofMentalHealthImprovementinScotland2008-11.Downloadedfrom:<http://www.scotland.gov.uk/Publications/2007/10/26112853/1>54Terjesen,M.,Jacofsky,M.,Froh,J.&DiGiuseppe,R.(2004)Integratingpositivepsychologyintoschools:Implicationsforpractice.PsychologyintheSchools,Vol.41(1),200455Grant,F.,Guille,C.&Sen,S.(2013)Well-BeingandtheRiskofDepressionunderStress.PLoSOne.8(7):e67395.56Keyes,C.,Dhingra,S.,Simoes,E.(2010)ChangeinLevelofPositiveMentalHealthasaPredictorofFutureRiskofMentalIllness.AmericanJournalofPublicHealth,100(12)
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Keyes(2002)suggeststhatalthoughmentalillnessandmentalwellbeingaredistinct,thereareenoughcommonunderlyingfactorstojustifyrepresentingmentalhealthasbeingonacontinuumwhichmovesfromafullmentalhealthdisordertoflourishingatthepopulationlevel.57ThestagesofKeyes’continuumareflourishing,moderatelymentallyhealthy,languishing,andDSM-III-Rmajordepressiveepisode.Inagivenpopulation,themajorityofpeoplearelanguishingormoderatelymentallyhealthy,andonlyaminorityhaveaclinicallydiagnosablementalillnessorcanbesaidtobeflourishing.58
Figure2:FiguretakenfromHuppert,F.(2009)PsychologicalWellbeing:Evidenceregardingitscausesandconsequences
Evidencefromepidemiologysuggeststhatifthekeyconcernistoreducethenumberofindividualswithclinicallysignificantdisorders,ratherthanfocusingontreatmentandcureforthisgroup,itmaybemoreeffectivetotargetthelargeproportionofthepopulationwithsymptomswhicharenotyetclinicallysignificant(sub-thresholdsymptoms)orwhoarefreefrommentalhealthproblemsbutnotflourishing.59
Thetheoryisthatshiftingtheoveralllevelsofwellbeingofthepopulationreducesthenumberofpeoplewhoarelanguishing,andmorelikelytodevelopmentalhealthdisorders,andincreasestheproportionwhoaremoderatelymentallyhealthyandflourishing,andthuslesslikelytodevelopmentalhealthdisorders,therebyreducingtheoveralllevelsofmentalhealthdisorderinthepopulation.
Figure3:FiguretakenfromHuppert,F.(2009)PsychologicalWellbeing:Evidenceregardingitscausesandconsequences
Empirically,thereisevidenceofarelationshipbetweenaveragelevelsofwellbeinginapopulationandtheproportionofindividualsexperiencingmentalhealthdisorders.FelicityHuppertpointstoastudywhichcomparedtheaveragelevelsofpsychologicaldistressandtheincidenceofclinicallysignificantdisordersinanumberofpopulationgroupsthatdifferedintermsofsocio-demographiccharacteristics.Thestudyfoundacrossthegroups,therewasaclearrelationshipbetweenthepercentageofpeopleexperiencingaclinicallysignificantcommonmentaldisorderandthemeanlevelofsymptomsofmentaldistress.Theirmodelsuggestedthatasmallchangeinthemeanscoresformentaldistresswouldleadtoarelativelylargechangeintheprevalenceofcommonmentaldisordersinthatpopulation.Afollow-upstudybroadlyconfirmedthisfinding.WhittingtonandHuppertfound“a linear relationship between the decrease in the mean symptom score and the decrease in the percentage of people who had clinically significant disorder. For every one point decrease on the symptom scale, the prevalence of disorder dropped by 6%. Moreover, as the mean number of symptoms decreased, a higher percentage of the sample moved into a no-symptom category, which could be described as flourishing.”60
Thisrelationshipbetweentheprevalenceofadisorderandtheaveragelevelsofunderlyingsymptomsorriskfactorsinthepopulationisalsopresentformanyothercommonphysicalandmentaldisorders,includingalcoholism,gamblingaddictionandhypertensionandheartdisease.61Foralloftheseconditions,”[i]f the mean number of symptoms in a particular population is low, it turns out that the percentage of people who meet criteria for a common disorder is low; if the mean number of symptoms in a population is high, the percentage of people who meet criteria is high.”62
Thissuggeststhatinsofarasthecontributingfactorstomentalwellbeingandpoormentalhealthareshared,interventionsthatcanachieveasmallshiftintheoveralllevelofwellbeingofthepopulationcouldhaveadisproportionatelylargeeffectonthenumbersexperiencingmentalhealthproblems.
Insofarascontributingfactorsarenotthesameformentalillhealthandgoodmentalhealth,mentalhealthpromotionwillresultinhealthbenefitsforthepopulationoverandabovereductioninillhealth,whichisagoodthinginitself.
Takentogether,thesefactssuggestthateffortstoincreasethelevelsofwellbeinginapopulationmaybeamoreeffectivewayofreducingtheincidenceofcommonmentalandbehaviouralproblemsthanfocusingontreatmentorriskreduction.63
57Keyes,C.(2002)TheMentalHealthContinuum:FromLanguishingtoFlourishinginLife.JournalofHealthandSocialBehavior,43(2):207-222.58Keyes,C.(2002)TheMentalHealthContinuum:FromLanguishingtoFlourishinginLife.JournalofHealthandSocialBehavior,43(2):207-222.59Huppert,F.(2009)PsychologicalWell-being:EvidenceRegardingitsCausesandConsequences.AppliedPsychology:HealthandWellbeing1(2):137-164.60Huppert,F.A.(2009),Anewapproachtoreducingdisorderandimprovingwell-being,PerspectivesonPsychologicalScience4(1),108-111.61Huppert,F.A.(2009),Anewapproachtoreducingdisorderandimprovingwell-being,PerspectivesonPsychologicalScience4(1),108-111.62Huppert,F.A.(2009),Anewapproachtoreducingdisorderandimprovingwell-being,PerspectivesonPsychologicalScience4(1),108-111.
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Improves physical healthWellbeingalsohasapositiveeffectonphysicalhealth.Alargenumberofcross-sectionalandlongitudinalstudieshaveshownthatpositivementalstatesareassociatedwithbetterphysicalhealthandgreaterlongevity.64,65Theeffectofpositivementalstatesonimmunityhasalsobeenconvincinglydemonstrated.Severalstudieshaveshownthatindividualswhohaveapositiveemotionalstylearelesslikelytobecomeillaftercontrolledexposuretoavirus,66andproducemoreantibodiesinresponsetovaccination.67Studies
havealsoindicatedthatinducingapositivementalstate(throughmeditation)increasesantibodyproductionrelativetoacontrolgroup.68
Inadditiontohavingadirectimpactonhealththroughimmuneandhormonalresponses,individualswithahighlevelofwellbeingalsotendtohavehealthierlifestyles.Theyalsotendtohavestrongerandmorepositiveinterpersonalrelationships,whichareknowntohaveaprotectiveeffectonhealthandlifeexpectancy.69
How can wellbeing be promoted?Althoughgenetic,demographicandsocioeconomicfactorsaffectwellbeing,studiessuggestthatthesefixedfactorsandlifecircumstancestogetheraccountforonlyaround60%ofthethevariationinwellbeingbetweenindividuals.70Theother40%ofthevariationinwellbeingisdrivenbyfactorsthatareunderindividuals’control.Inotherwordsintentionalactivities,includingbehaviours,cognitionsandmotivationsarealsoimportantdriversofpsychologicalwellbeing.71Manypsychologistsnowbelievethatinterventionsthattargetbehaviours,cognitionsandmotivationshavethepotentialtoimprovewellbeing.
Overthelastfewyears,proponentsofpositivepsychologyhavebeenlookingatwhathappypeoplecharacteristicallythinkanddo,examiningtheirhabits,behaviours,cognitivepatterns(includinggratefulandoptimisticthinking,andprosocialbehavior).72Theyhavebeendevisingpositiveactivitieswhichreplicatethesecharacteristics,andtestingoutwhetherpractisingtheseactivitiescanincreasewellbeinginothers.Lyubomirskydefinespositiveactivitiesas“simple, intentional, and regular practices meant to mimic the myriad healthy thoughts and behaviors associated with naturally happy people”.73Manypositiveactivitieshavebeenshowntoeffectivelyincreasebothsubjectivewellbeing(positiveaffectandlifesatisfaction)andpsychologicalwellbeing(effectivefunctioning).Theseactivitiesincludewritinggratitudeletters,countingblessings,performingactsofkindness,cultivatingstrengths,visualisingpositivefutureselvesandmeditating.74AsLyubomirskypointsout,aswellasbeingeffective,allthesepracticesarecheap,brief,andcanbedonewithoutoutsidehelp.75
SinandLyubormirsky(2009)conductedameta-reviewofrandomisedcontrolledstudiesofpositivepsychologyinterventions,includingmindfulnessinterventions(whichtheydefineas“treatment methods or intentional activities aimed at cultivating positive feelings, positive behaviors, or positive cognitions”).76Lookingat51interventions,across4,266individuals,theyfoundthattheseinterventions,whichpromptedpeopletothinkgratefully,optimisticallyormindfully,didsignificantlyimprovewellbeing,andalsosignificantlyreducedsymptomsofdepression.77Subsequentmeta-reviewshavebackedupthefindingthatpositivepsychologyiseffectiveinimprovingwellbeingandreducingdepression.Bolieretal(2013)conductedasimilarmeta-reviewofrandomisedcontrolledstudiesinvestigatingtheeffectofpositivepsychologyinterventions,andalsofoundtheinterventionshadasignificant,althoughsmall,effectonwellbeinganddepression,andthattheeffectonwellbeingpersistedevenafter3–6months.78Mindfulnessinterventionswereexcludedfromthisstudybecausetheireffectivenesshadalreadybeenconvincinglydemonstrated.
Inadditiontothesereviews,meditationandmindfulness-basedtherapieshavebeenseparatelytestedandfoundtobeeffectiveinimprovingmentalhealthandwellbeingbothinindividualswithdiagnosedmentalproblems,andalsointhosewithout.79,80,81ProfessorMarkWilliamsfromtheUniversityofOxfordDepartmentofPsychiatryhascalledtheevidencefortheireffectiveness“incontrovertible”.82
63Huppert,F.(2009)PsychologicalWell-being:EvidenceRegardingitsCausesandConsequences.AppliedPsychology:HealthandWellbeing1(2):137-164.64Bolier,L.,Haverman,M.,Westerhof,G.,Riper,H.,Smit,F.,Bohlmeijer,E.(2013).Positivepsychologyinterventions:ameta-analysisofrandomizedcontrolledstudies.BMCPublicHealth,13:11965Huppert,F.(2009)PsychologicalWell-being:EvidenceRegardingitsCausesandConsequences.AppliedPsychology:HealthandWellbeing1(2):137-164.66Cohen,S.,Alper,C.Doyle,W.,Treanor,J.&Turner,R.(2006)PositiveEmotionalStylePredictsResistancetoIllnessAfterExperimentalExposuretoRhinovirusorInfluenzaAVirus.PsychosomaticMedicine68(6):809-15.67http://www.ncbi.nlm.nih.gov/pmc/articles/PMC196942/68SeeHuppert,F.(2009)PsychologicalWell-being:EvidenceRegardingitsCausesandConsequences.AppliedPsychology:HealthandWellbeing1(2):137-164.69Huppert,F.(2009)PsychologicalWell-being:EvidenceRegardingitsCausesandConsequences.AppliedPsychology:HealthandWellbeing1(2):137-164.70Boehm,J.K.,&Lyubomirsky,S.(2011).Thepromiseofsustainablehappiness.InS.Lopez&C.Snyder(Ed.),Handbookofpositivepsychology(2nded.).Oxford:OxfordUniversityPress.71Lyubomirsky,S.,Schkade,D.&Sheldon,K.(2005)PursuingHappiness:TheArchitectureofSustainableChangeReviewofGeneralPsychology9(2)111–131. 72 Lyubomirsky,S.(2001).Whyaresomepeoplehappierthanothers?Theroleofcognitiveandmotivationalprocessesinwell-being.AmericanPsychologist,56:239-249.73Lyubomirsky,S.,&Layous,K.(2013)Howdosimplepositiveactivitiesincreasewell-being?CurrentDirectionsinPsychologicalScience,22(1):57-62. 74Lyubomirsky,S.,&Layous,K.(2013)Howdosimplepositiveactivitiesincreasewell-being?CurrentDirectionsinPsychologicalScience,22(1):57-62.75Lyubomirsky,S.,&Layous,K.(2013)Howdosimplepositiveactivitiesincreasewell-being?CurrentDirectionsinPsychologicalScience,22(1):57-62.76Sin,N.L.,&Lyubomirsky,S.(2009)Enhancingwell-beingandalleviatingdepressivesymptomswithpositivepsychologyinterventions:Apractice-friendlymeta-analysis.JournalofClinicalPsychology:InSession,65:467-487.77Sin,N.L.,&Lyubomirsky,S.(2009)Enhancingwell-beingandalleviatingdepressivesymptomswithpositivepsychologyinterventions:Apractice-friendlymeta-analysis.JournalofClinicalPsychology:InSession,65:467-487.78 Bolier,L.,Haverman,M.,Westerhof,G.,Riper,H.,Smit,F.,Bohlmeijer,E.(2013)Positivepsychologyinterventions:ameta-analysisofrandomizedcontrolledstudies.BMCPublicHealth13:119.79Hofmann,S.,Sawyer,A.etal(2010)TheEffectofMindfulness-BasedTherapyonAnxietyandDepression:AMeta-AnalyticReview,Journalofconsultingandclinicalpsychology87(2):169-183.80Halliwell,E(nd)MindfulnessReport.London:MentalHealthFoundation.81Khoury,B.,Lecomte,Y.etal(2013)Mindfulness-basedtherapy:Acomprehensivemeta-analysis.ClinicalPsychologyReview33:763–771.82Halliwell,E(nd)MindfulnessReport.London:MentalHealthFoundation.
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ConclusionThereisaclearcasetobemadeforpublichealthinterventionstofocusonpromotingwellbeingasapreventativemeasure,andnotaddressingwellbeinginterventionsonlytothosewithdiagnosablesymptomsofmentaldistress.Thereisalsogoodevidencethatwellbeingcanbeimprovedthroughpositivepsychologyinterventions,mindfulnessandmeditation.Youngpeopleareaparticularlyimportanttargetforthesetypesofwellbeinginterventions,asimprovementstomentalhealthinchildhoodandadolescencecanhavealargepositiveeffectoverthelifecourse.
Thisraisesthechallengeofreachinglargenumbersofyoungpeoplewithoutspecificmentalhealthconditions,andencouragingthemtoengageinactivitiesthatpromotementalwellbeing.